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IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT_

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IN THE CIRCUIT COURT OF THE JUDICIAL CIRCUIT_ Powered By Docstoc
					           IN THE CIRCUIT COURT OF THE ____________________JUDICIAL CIRCUIT,
                IN AND FOR                           COUNTY, FLORIDA

                                                            Case No.:
                                                            Division:
                                                 ,
                                   Petitioner,

                 and

                                                 ,
                                 Respondent.

                               FAMILY LAW FINANCIAL AFFIDAVIT
                               ($50,000 or more Individual Gross Annual Income)

         I, {full legal name}                                                            , being sworn,
certify that the following information is true:

SECTION I. INCOME

1.      Date of Birth:

2.      My occupation is:

3.        I am currently
[  all that apply]
                  a. Unemployed
                  Describe your efforts to find employment, how soon you expect to be employed, and the
                  pay you expect to receive:


        ____     b. Employed by:
                 Address:
                 City, State, Zip code:
                 Telephone Number:
                 Pay rate: $               ( ) every week ( ) every other week ( ) twice a month
                 ( ) monthly ( ) other:
                 If you are expecting to become unemployed or change jobs soon, describe the change you
                 expect and why and how it will affect your income:

                 second job(s) on a separate sheet and attach it to this affidavit.

                 c. Retired. Date of retirement:
                 Employer from whom retired:
                 Address:
                 City, State, Zip code:                                       Telephone Number:
LAST YEAR’S GROSS INCOME:                     Your Income                          Other Party’s Income (if known)

         YEAR                                 $                                    $

PRESENT MONTHLY GROSS INCOME:

All amounts must be MONTHLY. See the instructions with this form to figure out money amounts for anything that is NOT
paid monthly. Attach more paper, if needed. Items included under “other” should be listed separately with separate dollar
amounts.

1. Monthly gross salary or wages                                                             1. $
2. Monthly bonuses, commissions, allowances, overtime, tips, and similar                     payments
3. Monthly business income from sources such as self-employment,                             2.
    partnerships, close corporations, and/or independent contracts (Gross
    receipts minus ordinary and necessary expenses required to produce
    income.)
    (                                                                                        3.
4. Monthly disability benefits/SSI                                                           4.
5. Monthly Workers’ Compensation                                                             5.
6. Monthly Unemployment Compensation                                                         6.
7. Monthly pension, retirement, or annuity payments                                          7.
8. Monthly Social Security benefits                                                          8.
9. Monthly alimony actually received
                9a. From this case:     $
                9b. From other case(s):               Add 9a and 9b                          9.
10. Monthly interest and dividends                                                           10.
11. Monthly rental income (gross receipts minus ordinary and necessary
    expenses required to produce income) (
    income and expense items.)                                                               11.
12. Monthly income from royalties, trusts, or estates                                        12.
13. Monthly reimbursed expenses and in-kind payments to the extent that

    and amount.)                                                                             13.
14. Monthly gains derived from dealing in property (not including
    nonrecurring gains)                                                                      14.
Any other income of a recurring nature (identify source)
15.     ________________________________________________________                             15.
16.     ________________________________________________________                             16.

17. PRESENT MONTHLY GROSS INCOME (Add lines 1–16) TOTAL: 17. $
PRESENT MONTHLY DEDUCTIONS:
All amounts must be MONTHLY. See the instructions with this form to figure out money amounts for anything that is NOT
paid monthly.
18. Monthly federal, state, and local income tax
    (corrected for filing status and allowable
    dependents and income tax liabilities)
        a. Filing Status
        b. Number of dependents claimed                        18.
19. Monthly FICA or self-employment taxes                      19.
20. Monthly Medicare payments                                  20.
21. Monthly mandatory union dues                               21.
22. Monthly mandatory retirement payments                      22.
23. Monthly health insurance payments
(including dental insurance),
    excluding portion paid for any minor                       23.
    children of this relationship
24. Monthly child court-ordered support
    actually paid for children from another
    relationship                                               24. __________
25. Monthly court-ordered alimony actually
paid
        25a. from this case:      $
        25b. from other case(s):
                  Add 25a and 25b                              25. __________

26. TOTAL DEDUCTIONS ALLOWABLE UNDER SECTION 61.30,
    FLORIDA STATUTES (Add lines 18 through 25) TOTAL: 26. $

27. PRESENT NET MONTHLY INCOME (Subtract line 26 from line 17)                            27. $

SECTION II. AVERAGE MONTHLY EXPENSES
Proposed/Estimated Expenses. If this is a dissolution of marriage case and your expenses as listed
below do not reflect what you actually pay currently, you should write “estimate” next to each amount
that is estimated.
HOUSEHOLD:
1. Monthly mortgage or rent payments                                  1. $
2. Monthly property taxes (if not included in mortgage)               2.
3. Monthly insurance on residence (if not included in mortgage)       3.
4. Monthly condominium maintenance fees and homeowner’s association   4.
    fees
5. Monthly electricity                                                5.
6. Monthly water, garbage, and sewer                                  6.
7. Monthly telephone                                                  7.
8. Monthly fuel oil or natural gas                                    8.
9. Monthly repairs and maintenance                                    9.
10. Monthly lawn care                                                 10.
11. Monthly pool maintenance                                          11.
12. Monthly pest control                                              12.
13. Monthly misc. household                                           13.
14. Monthly food and home supplies                                    14.
15. Monthly meals outside home                                        15.
16. Monthly cable t.v.                                                16.
17. Monthly alarm service contract                                    17.
18. Monthly service contracts on appliances                           18.
19. Monthly maid service                                              19.
Other:
20.                                                                   20.
21.                                                                   21.
22.                                                                   22.
23.                                                                   23.
24.                                                                   24.

25.                     SUBTOTAL (add lines 1 through 24)             25. $
AUTOMOBILE:
26. Monthly gasoline and oil                                          26. $
27. Monthly repairs                                                   27.
28. Monthly auto tags and emission testing                            28.
29. Monthly insurance                                                 29.
30. Monthly payments (lease or financing)                             30.
31. Monthly rental/replacements                                       31.
32. Monthly alternative transportation (bus, rail, car pool, etc.)    32.
33. Monthly tolls and parking                                         33.
34. Other:                                                            34.

35.                      SUBTOTAL (add lines 26 through 34)           35. $
MONTHLY EXPENSES FOR CHILDREN COMMON TO BOTH
PARTIES:
36. Monthly nursery, babysitting, or day care                                   36. $
37. Monthly school tuition                                                      37.
38. Monthly school supplies, books, and fees                                    38.
39. Monthly after school activities                                             39.
40. Monthly lunch money                                                         40.
41. Monthly private lessons or tutoring                                         41.
42. Monthly allowances                                                          42.
43. Monthly clothing and uniforms                                               43.
44. Monthly entertainment (movies, parties, etc.)                               44.
45. Monthly health insurance                                                    45.
46. Monthly medical, dental, prescriptions (nonreimbursed only)                 46.
47. Monthly psychiatric/psychological/counselor                                 47.
48. Monthly orthodontic                                                         48.
49. Monthly vitamins                                                            49.
50. Monthly beauty parlor/barber shop                                           50.
51. Monthly nonprescription medication                                          51.
52. Monthly cosmetics, toiletries, and sundries                                 52.
53. Monthly gifts from child(ren) to others (other children, relatives,
    teachers, etc.)                                                             53.
54. Monthly camp or summer activities                                           54.
55. Monthly clubs (Boy/Girl Scouts, etc.)                                       55.
56. Monthly access expenses (for nonresidential parent)                         56.
57. Monthly miscellaneous                                                       57.

58.                     SUBTOTAL (add lines 36 through 57)                      58. $

MONTHLY EXPENSES FOR CHILD(REN) FROM ANOTHER
RELATIONSHIP: (other than court-ordered child support)
59.                                                                             59. $
60.                                                                             60.
61.                                                                             61.
62.                                                                             62.

63.                     SUBTOTAL (add lines 59 through 62)                      63. $

MONTHLY INSURANCE:                                                              64. $

64. Health insurance, excluding portion paid for any minor child(ren) of this   65.
    relationship                                                                66.
65. Life insurance
66. Dental insurance                                                            67.
Other:                                                                          68.
67.
68.

69. SUBTOTAL (add lines 64 through 68)                                          69. $

OTHER MONTHLY EXPENSES NOT LISTED ABOVE:
70. Monthly dry cleaning and laundry                                            71. Monthly
clothing                                                                   70. $
72. Monthly medical, dental, and prescription (unreimbursed only)          71.
73. Monthly psychiatric, psychological, or counselor (unreimbursed only)   72.
74. Monthly non-prescription medications, cosmetics, toiletries, and       73.
     sundries                                                              74.
75. Monthly grooming                                                       75.
76. Monthly gifts                                                          76.
77. Monthly pet expenses                                                   77.
78. Monthly club dues and membership                                       78.
79. Monthly sports and hobbies                                             79.
80. Monthly entertainment                                                  80.
81. Monthly periodicals/books/tapes/CD’s                                   81.
82. Monthly vacations                                                      82.
83. Monthly religious organizations                                        83.
84. Monthly bank charges/credit card fees                                  84.
85. Monthly education expenses                                             85.
Other: (include any usual and customary expenses not otherwise mentioned
in the items listed above)
86.
87.                                                                        86.
88.                                                                        87.
89.                                                                        88.
                                                                           89.

90. SUBTOTAL (add lines 70 through 89)                                     90. $

MONTHLY PAYMENTS TO CREDITORS: (only when payments are
currently made by you on outstanding balances)NAME OF CREDITOR(s):
91.                                                                        91. $
92.                                                                        92.
93.                                                                        93.
94.                                                                        94.
95.                                                                        95.
96.                                                                        96.
97.                                                                        97.
98.                                                                        98.
99.                                                                        99.
100.                                                                       100.
101.                                                                       101.
102.                                                                       102.

                                                                           103.
                                                                                                   103.
104.                           SUBTOTAL (add lines 91 through 103)                                 104. $

105.      TOTAL MONTHLY EXPENSES:
          (add lines 25, 35, 58, 63, 69, 90, and 104 of Section II, Expenses)                      105. $

SUMMARY

106.      TOTAL PRESENT MONTHLY NET INCOME                                                         106. $______________

          (from line 27 of SECTION I. INCOME)
107.      TOTAL MONTHLY EXPENSES (from line 105 above)                                             107. $

108.     SURPLUS (If line 106 is more than line 107, subtract line 107 from
    line 106. This is the amount of your surplus. Enter that amount here.)                         108. $

109.    (DEFICIT) (If line 107 is more than line 106, subtract line 106                            109. $ _________
    from line 107. This is the amount of your deficit. Enter that amount
    here.)

SECTION III. ASSETS AND LIABILITIES
A. ASSETS (This is where you list what you OWN.)

INSTRUCTIONS:

STEP 1: In column A, list a description of each separate item owned by you (and/or your spouse, if this is a petition for
dissolution of marriage). Blank spaces are provided if you need to list more than one of an item.

STEP 2: If this is a petition for dissolution of marriage, check the box in Column A next to any item that you are requesting the
judge award to you.

STEP 3: In column B, write what you believe to be the current fair market value of all items listed.

STEP 4: Use column C only if this is a petition for dissolution of marriage and you believe an item is “nonmarital,”
meaning it belongs to only one of you and should not be divided. You should indicate to whom you believe the item belongs.
(Typically, you will only use Column C if property was owned by one spouse before the marriage. See the “General
Information for Self-Represented Litigants” found at the beginning of these forms and section 61.075(1), Florida Statutes, for
definitions of “marital” and “nonmarital” assets and liabilities.)



                                         A                                                      B                    C
                           ASSETS: DESCRIPTION OF ITEM(S)                                  Current Fair         Nonmarital
                                                                                           Market Value      (correct column)
  the box next to any asset(s) which you are requesting the judge award to you.


                                                                                                            husband      wife
    Cash (on hand)                                                                        $
    Cash (in banks or credit unions)

    Stocks/Bonds
Notes (money owed to you in writing)


Money owed to you (not evidenced by a note)


Real estate: (Home)
(Other)




Business interests




Automobiles




Boats


Other vehicles


Retirement plans (Profit Sharing, Pension, IRA, 401(k)s, etc.)




Furniture & furnishings in home

Furniture & furnishings elsewhere

Collectibles

Jewelry

Life insurance (cash surrender value)


Sporting and entertainment (T.V., stereo, etc.) equipment




Other assets
 Total Assets (add column B)                                                            $


B. LIABILITIES/DEBTS (This is where you list what you OWE.)

INSTRUCTIONS:

STEP 1: In column A, list a description of each separate debt owed by you (and/or your spouse, if this is a petition for
dissolution of marriage). Blank spaces are provided if you need to list more than one of an item.

STEP 2: If this is a petition for dissolution of marriage, check the box in Column A next to any debt(s) for which you believe
you should be responsible.

STEP 3: In column B, write what you believe to be the current amount owed for all items listed.

STEP 4: Use column C only if this is a petition for dissolution of marriage and you believe an item is “nonmarital,”
meaning the debt belongs to only one of you and should not be divided. You should indicate to whom you believe the debt
belongs. (Typically, you will only use Column C if the debt was owed by one spouse before the marriage. See the “General
Information for Self-Represented Litigants” found at the beginning of these forms and section 61.075(1), Florida Statutes, for
definitions of “marital” and “nonmarital” assets and liabilities.)



                                         A                                                   B                    C
                        LIABILITIES: DESCRIPTION OF ITEM(S)                                Current            Nonmarital
                                                                                         Amount Owed      ( correct column)
  the box next to any debt(s) for which you believe you should be responsible.


                                                                                                          husband     wife
    Mortgages on real estate: (Home)                                                    $
    (Other)


   Charge/credit card accounts




   Auto loan
   Auto loan
   Bank/Credit Union loans
   Money you owe (not evidenced by a note)

   Judgments

   Other




 Total Debts (add column B)                                                                   $

C. NET WORTH (excluding contingent assets and liabilities)

           Total Assets (enter total of Column B in Asset Table; Section A)                                     $
           Total Liabilities (enter total of Column B in Liabilities Table; Section B)                          $

           TOTAL NET WORTH (Total Assets minus Total Liabilities)
           (excluding contingent assets and liabilities)                                                        $

D. CONTINGENT ASSETS AND LIABILITIES

INSTRUCTIONS:

If you have any POSSIBLE assets (income potential, accrued vacation or sick leave, bonus, inheritance, etc.) or POSSIBLE
liabilities (possible lawsuits, future unpaid taxes, contingent tax liabilities, debts assumed by another), you must list them here.



                                            A                                                        B                  C
                                     Contingent Assets                                                              Nonmarital
                                                                                               Possible Value   ( correct column)
  the box next to any contingent asset(s) which you are requesting the judge award to you.
                                                                                                                husband     wife
                                                                                              $




 Total Contingent Assets                                                                      $




                                            A                                                        B                  C
                                   Contingent Liabilities                                                           Nonmarital
                                                                                              Possible Amount   ( correct column)
  the box next to any contingent debt(s) for which you believe you should be responsible.         Owed



                                                                                                              husband   wife
                                                                                              $




 Total Contingent Liabilities                                                                 $

E. Has there been any agreement between you and the other party that one of you will take responsibility
for a debt and will hold the other party harmless from that debt? ( ) yes ( ) no
If yes, explain:




F. CHILD SUPPORT GUIDELINES WORKSHEET. __ Florida Family Law Rules of Procedure
Form 12.902(e), Child Support Guidelines Worksheet, MUST be filed with the court at or prior to a
hearing to establish or modify child support. This requirement cannot be waived by the parties.
[  one only]
                 A Child Support Guidelines Worksheet IS or WILL BE filed in this case. This case
        involves the establishment or modification of child support.
                 A Child Support Guidelines Worksheet IS NOT being filed in this case. The
        establishment or modification of child support is not an issue in this case.

I certify that a copy of this financial affidavit was: (                  ) mailed, (        ) faxed and mailed, or (   ) hand
delivered to the person(s) listed below on {date}                                                                             .

Other party or his/her attorney:
Name:
Address:
City, State, Zip:
Fax Number:

        I understand that I am swearing or affirming under oath to the truthfulness of the claims
made in this affidavit and that the punishment for knowingly making a false statement includes
fines and/or imprisonment.

Dated:



                                                               Signature of Party
                                                               Printed Name:
                                               Address:
                                               City, State, Zip:
                                               Telephone Number:
                                               Fax Number:

STATE OF FLORIDA
COUNTY OF

Sworn to or affirmed and signed before me on                       by                            .



                                                       NOTARY PUBLIC or DEPUTY CLERK

                                                       [Print, type, or stamp commissioned name of
                                                       notary or deputy clerk .]
       Personally known
       Produced identification
       Type of identification produced

IF A NONLAWYER HELPED YOU FILL OUT THIS FORM, HE/SHE MUST FILL IN THE
BLANKS BELOW: [ fill in all blanks]
I, {full legal name and trade name of nonlawyer}                                   ,
a nonlawyer, located at {street}                                          , {city} ,
{state}                   , {phone}                     , helped {name}            ,
who is the [  one only]      petitioner or respondent, fill out this form.

				
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